Pulmonary Flashcards
Classification of Asthma Severity in Adults (12 years +)
Frequency of symptoms
2 days or less/week = Intermittent
> 2 days/week but not daily = Mild Persistent
Daily = Moderate Persistent
Throughout the day = Severe Persistent
Classification of Asthma Severity in Adults (12 years +)
Nighttime awakening
2x or less/month = Intermittent
3-4x/month = Mild Persistent
More than once weekly but not nightly = Moderate Persistent
Often 7x/week = Severe Persistent
Classification of Asthma Severity in Adults (12 years +)
SABA use for symptom control
2 days or less/week = Intermittent
> 2 days/week but not daily = Mild Persistent
Daily = Moderate Persistent
Several times a day = Severe Persistent
Classification of Asthma Severity in Adults (12 years +)
Interference with activity
None = Intermittent
Minor limitation = Mild Persistent
Some limitations = Moderate Persistent
Extremely limited = Severe Persistent
Classification of Asthma Severity in Adults (12 years +)
FEV1 (% of normal)
> 80% (normal) = Intermittent
> 80% (normal) = Mild Persistent
> 60% to < 80% = Moderate Persistent
< 60% = Severe Persistent
Classification of Asthma Severity in Adults (12 years +)
Exacerbations requiring oral steroids
0-1/year = Intermittent
2 or more/year = Mild Persistent
2 or more/year = Moderate Persistent
2 or more/year = Severe Persistent
What is the recommended step for initiating treatment in asthma patients?
Intermittent = Step 1
Mild Persistent = Step 2
Moderate Persistent = Step 3 and consider short course of oral steroids
Severe Persistent = Step 4 or 5 and consider short course of oral steroids
When assessing asthma control, when would a patient be considered well controlled?
Symptoms = 2 days or less/week
Nighttime awakenings = 2x or less/month
Interference w/ normal activity = None
SABA use for symptom control = 2 days or less/week
Exacerbations requiring oral steroids = 0-1x/year
Recommended Treatment:
-Maintain current step
-Regular follow-up every 1-6 months
-Consider step-down if well control for 3+ months
When assessing asthma control, when would a patient be considered not well controlled?
Symptoms = > 2 days/week
Nighttime awakenings = 1-3x/week
Interference w/ normal activity = Some limitations
SABA use for symptom control = > 2 days/week
Exacerbations requiring oral steroids = 2x or more/year
Recommended Treatment:
-Step up one step
-Re-evaluate in 2-6 weeks
When assessing asthma control, when would a patient be considered very poorly controlled?
Symptoms = Throughout the day
Nighttime awakenings = 4x or more/week
Interference w/ normal activity = Extremely limited
SABA use for symptom control = Several times a day
Exacerbations requiring oral steroids = 2x or more/year
Recommended Treatment:
-Consider short course of oral steroids
-Step-up one-to-two steps
-Re-evaluate in 2 weeks
What are the instructions if using ICS/formoterol SMART inhaler therapy?
1-2 puffs (4.5 mcg of formoterol/puff) every 4 hours as needed
Max of 12 puffs/day
What is the recommended inhaler therapy for Step 1 in asthma?
NHLBI = No controller needed
2020 Focused Updates = SABA PRN
GINA
-Track 1: low-dose ICS/formoterol PRN
-Track 2: low-dose ICS when SABA is taken
Per NHLBI asthma treatment recommendations, what inhaler therapy is recommended for all steps?
SABA PRN
*if patients using ICS/formoterol as controller in Steps 3/4, can consider using PRN for quick relief
What is the recommended inhaler therapy for Step 2 in asthma?
NHLBI = Low-dose ICS or PRN concomitant ICS + SABA
2020 Focused Updates = Low-dose ICS or PRN concomitant ICS + SABA
GINA
-Track 1: low-dose ICS/formoterol PRN
-Track 2: low-dose ICS
What is the recommended inhaler therapy for Step 3 in asthma?
NHLBI = Low-dose ICS/formoterol
2020 Focused Updates = Low-dose ICS/formoterol
*Alternate: Medium-dose ICS
GINA
-Track 1: low-dose ICS/formoterol
-Track 2: low-dose ICS/LABA
What is the recommended inhaler therapy for Step 4 in asthma?
NHLBI = Medium-dose ICS/formoterol
2020 Focused Updates = Medium-dose ICS/formoterol
GINA
-Track 1: medium-dose ICS/formoterol
-Track 2: medium-to-high-dose ICS/LABA
What is the recommended inhaler therapy for Step 5 in asthma?
NHLBI = Medium-to-high-dose ICS/LABA + LAMA; consider biologics for patients with allergic asthma
2020 Focused Updates = Medium-to-high-dose ICS/LABA + LAMA; consider biologics for patients with allergic asthma
GINA
-Track 1: add on LAMA; consider high-dose ICS/formoterol
-Track 2: add on LAMA; consider high-dose ICS/LAMA
What is the recommended inhaler therapy for Step 6 in asthma?
NHLBI = High-dose ICS/LABA plus systemic corticosteroids; consider biologics for patients with allergic asthma
2020 Focused Updates = High-dose ICS/LABA plus systemic corticosteroids; consider biologics for patients with allergic asthma
GINA = nothing mentioned
What black box warning does Montelukast carry?
Neuropsychiatric symptoms
What are side effects of LAMAs?
-Dry mouth
-Blurred vision
-Tachycardia
-Palpitations
-Bitter or sweet taste
What are side effects of LABAs?
-Tremors
-Tachycardia
What are side effects of ICSs?
-Oral candidiasis
-Hoarseness
How is COPD diagnosed?
FEV1/FVC < 0.7
What is GOLD grade 1?
Mild; FEV1 80% or greater of predicted
What is GOLD grade 2?
Moderate; FEV1 50% or greater and less than 80% of predicted
What is GOLD grade 3?
Severe; FEV1 30% of greater and less than 50% of predicted
What is GOLD grade 4?
Very Severe; FEV1 < 30% of predicted
Which COPD group would the following fit into?
-1 or less exacerbations/year NOT leading to hospitalization
-mMRC 0-1 OR CAT < 10
A
Which COPD group would the following fit into?
-1 or less exacerbations/year NOT leading to hospitalization
-mMRC 2 or more OR CAT 10 or more
B
Which COPD group would the following fit into?
-2 or more exacerbations/year OR 1+ w/ hospitalization
-Fewer or more symptoms
E
What is the recommended initial treatment for patients with COPD group A?
Bronchodilator
What is the recommended initial treatment for patients with COPD group B?
LABA + LAMA
What is the recommended initial treatment for patients with COPD group E?
LABA + LAMA
*Consider LABA + LAMA + ICS if eos > 300 and/or history of or concurrent asthma
How should inhaler therapy be adjusted for patients who predominantly experience dyspnea per GOLD guidelines?
LABA or LAMA -> LABA + LAMA
-Consider switching inhaler device
-Implement or escalate non-pharm treatment
-Investigate (and treat) other causes of dyspnea
How should inhaler therapy be adjusted for patients who predominantly experience exacerbations per GOLD guidelines?
LABA or LAMA -> LABA + LAMA + ICS (if eos 300+) -> Roflumilast (FEV1 < 50% and chronic bronchitis) or azithromycin
LABA or LAMA -> LABA + LAMA (if eos < 300) -> LABA + LAMA + ICS (if eos 100+)
What are side effects of roflumilast?
-Diarrhea
-Weight loss/decreased appetite
-Insomnia
-Dizziness
-Back pain
What is a COPD exacerbation?
Acute worsening of patient’s baseline respiratory symptoms that is worse than normal day-to-day variation
-Dyspnea and/or cough and/or an increase in quantity or purulence of sputum
What is the preferred initial treatment of a COPD exacerbation?
Inhaled SABA with/without SAMA
AND
Prednisone 40 mg for 5-7 days
When are antibiotics indicated during a COPD exacerbation?
Presence of 2 of the 3 cardinal symptoms:
-Increased dyspnea
-Increased sputum volume
-Increased sputum purulence*
What antibiotics are appropriate for a COPD exacerbation?
Uncomplicated:
-Azithromycin, clarithromycin
-Doxycycline
-Amoxicillin +/- clavulanate
Complicated (comorbid diseases, severe COPD, more than 3 exacerbations/year, antibiotic use in past 3 months)
-Amoxicillin/clavulanate
-Levofloxacin
-Moxifloxacin
How long should antibiotics be used for a COPD exacerbation?
5-7 days
What are the “5 A’s” of tobacco cessation?
-Ask
-Assess (current use, motivations, history)
-Advise
-Assist (offer and connect to treatment)
-Arrange (follow-up)
What does STAR refer to when helping patients design a quit plan?
-Set a quit date (within 2 weeks is ideal)
-Tell family, friends, coworkers
-Anticipate challenges (including withdrawal)
-Remove tobacco products/paraphernalia from environment
Per ACC guidelines, what is the recommended first-line therapy for tobacco cessation?
Combination NRT therapy
OR
Varenicline monotherapy
